Bahadir Dagdeviren

Echocardiographic prediction of long-term response to biventricular pacemaker in severe heart failure

Biventricular pacing substantially improves LV systolic function and symptom status in some patients with dilated cardiomyopathy.

Noncompaction of ventricular myocardium, complete atrioventricular block and minor congenital heart abnormalities: case report of an unusual coexistence.

Ventricular noncompaction is a rare cardiomyopathy characterized by numerous, prominent ventricular trabeculations and deep intertrabecular recesses and is caused by a disorder of endomyocardial morphogenesis. It can occur in patients with other congenital anomalies, such as various ventricular obstructive lesions, or in isolated form in the absence of associated anomalies. Patients with this unique disease may present with heart failure, systemic emboli, and ventricular arrhythmias. In this case report, we present an unusual coexistence of ventricular noncompaction and atrial septal aneurysm and mitral valve cleft in a young patient who presented with complete AV-block.

The effects of hormonal therapy on aortic stiffness and left ventricular diastolic function.

Objective — The main objective of this study is to investigate the effects of oestrogen replacement therapy (ERT) and hormone replacement therapy (HRT) on aortic stiffness and on the left ventricular diastolic function, including tissue Doppler. Methods and results — The two study groups were composed of 20 postmenopausal women having HRT and 22 postmenopausal women having ERT. Each group was evaluated for aortic elasticity properties and the left ventricular diastolic function at both the pre-treatment stage and after 12 weeks of hormonal therapy.There was a significant improvement in beta index (5.2±2.5 vs. 3.2±2.2, p = 0.001), distensibility (5.2±3.7 vs. 6.1±4.1 cm2.dyn-1.10-3, p = 0.036) and mitral E/Em ratio (7.44±3.25 vs. 5.75±.2.34, p = 0.004) with ERT. HRT was observed to improve aortic elasticity properties (for strain 10.7±4.7 vs. 12.8±7.6%, for beta index 4.9±2.1 vs. 3.39±2.4 and for distensibility 4.6±2.1 vs. 5.69±4.1 cm2.dyn-1.10-3) and the mitral E/Em ratio (7.61±3.31 vs. 5.81±2.31, p = 0.003). Conclusion — Both ERT and HRT have an improving effect on aortic elasticity properties, as well as on the diastolic function.

Aortic stiffness in patients with cardiac syndrome X.

Aim — Recently, the close relationship between aortic stiffness and cardiovascular mortality has aroused the interest of investigators in carrying out studies related to aortic stiffness.This study aims to investigate the aortic stiffness parameters in patients with cardiac syndrome X, a disorder that is believed to be a generalized disturbance of the vasodilator function of small arteries. Material and methods — 18 patients with typical chest pain and angiographically normal coronary arteries associated with a positive exercise test were included in the study. The control group consisted of 27 patients with angiographically normal coronary arteries and no ischaemia on exercise testing. Antianginal medication was withheld 4 weeks before the study and transthoracic echocardiography was performed using a Hewlett-Packard Sonos 1500 instrument with a 2.5 MHz phased array transducer. Ascending aorta diameters were measured on the M-mode tracing at a level 3 cm above the aortic valve. Diameter change, pulse pressure, aortic strain and distensibility were measured as aortic stiffness parameters. Results —The aortic diameter change was less in the syndrome X group than in the control group (0.15±0.04 cm/m2 vs. 0.28±0.12 cm/m2, p<0.001). Likewise, aortic strain (9±3% vs. 18±8%, p<0.001) and distensibility (4.01±1.71 cm2.dyn-1.10-3 vs. 9.95±5.08 cm2.dyn-1.10-3, p<0.001) was significantly lower in the syndrome X group than in the control group. Conclusion—The deterioration in aortic elasticity properties in patients with cardiac syndrome X suggests that this disease may be a more generalized disturbance of the vasculature.

Assessment of the effects of various maneuvers on both atrial pressure changes

The aim of the present study was to determine which maneuver causes the greatest pressure difference between both atria by measuring right and left atrial pressures simultaneously after certain maneuvers. Thirty-two coronary care unit patients, whom a Swan-Ganz catheter was inserted because of acute left ventricular dysfunction, hypotension, sinus tachycardia with unknown cause, were included in this study. The basal values of peak right atrium (RA) pressure and corresponding pulmonary capillary wedge pressure (PCWP) were measured via two separated transducers. Patients were tutored with several trials to perform breath holding, successive three strong coughs, Valsalva maneuver, 20 degrees head down, respectively. In the end of these maneuvers, the peak RA pressure and corresponding PCWP were measured simultaneously. All maneuvers caused an increase in RA pressure. The highest peak RA pressure was obtained by means of the Valsalva maneuver (7.6 +/- 5 versus 20.4 +/- 7.6 mmHg before and after Valsalva, respectively; P<0.001). PCWP (18.8 +/- 5.9 mmHg) increased only with coughing (21.2 +/- 6.7 mmHg, P<0.01) and 20 degrees head down maneuver (20 +/- 5.7 mmHg, P<0.05). The highest increase in pressure gradient between peak RA pressure and corresponding PCWP was observed during Valsalva maneuver (-11 +/- 6.6 vs. 2.3 +/- 5.9 mmHg, P<0.001). The lowest increase was obtained in 20 degrees head down maneuver (-11 +/- 6.6 vs. -8.5 +/- 5.8 mmHg, P<0.001). When measuring the pressure of both atria invasively and simultaneously, Valsalva maneuver was the most effective maneuver consistent with pressure difference in favour of RA among all the other maneuvers.

Correlation Between Doppler Derived dP/dt and Left Ventricular Asynchrony in Patients with Dilated Cardiomyopathy: A Combined Study Using Strain Rate Imaging and Conventional Doppler Echocardiography

Aim: To evaluate the relationship between Doppler‐derived left ventricular (LV) dP/dt and the degree of LV mechanical asynchrony measured by strain rate imaging. Methods and results: The study group consisted of 69 patients with variable degree of LV dysfunction and mitral regurgitation (MR). Conventional echo variables and LV dP/dt were calculated from the MR Doppler spectrum by rate‐pressure‐rise method. Strain rate traces were obtained by 12‐segment model and LV long axis images were analyzed off‐line. The longest time intervals between the peak negative strain rate waves at isovolumic contraction period and peak systole from reciprocal segments were defined as asynchrony index AIc or AIs, respectively. The maximum differences in time‐to‐peak systolic velocities between opposing walls were also measured as asynchrony index by tissue Doppler (AItd). The dP/dt, mean QRS duration, AIc, AIs, and AItd were 836 ± 266 mmHg/sec, 125 ± 31, 38 ± 28, 64 ± 44, and 52 ± 32 m, respectively. No significant correlation between the dP/dt and the LV dimension, ejection fraction or QRS duration was observed. However, dP/dt correlated negatively with AIc, or AIs (r:‐0.78, −0.72, P ≤ 0.0001) and AItd (r:‐0.65, P ≤ 0.001). A cutoff dP/dt value of under 700 mmHg/sec can discriminate patients over median AIs (55 ms) or patients with AIc over 30 ms with high sensitivity and specificity. Conclusions: Doppler‐derived LV dP/dt is related to the degree of LV dyssynchrony rather than the conventional systolic function indices such as EF% in patients with severe heart failure. Noninvasive dP/dt assessment in addition to advanced imaging techniques can be used to define patients for cardiac resynchronization therapy (CRT).

Right ventricular function in patients with acute anterior myocardial infarction: tissue Doppler echocardiographic approach.

Objective — Our purpose was to investigate the right ventricular (RV) performance of patients with a first acute anterior myocardial infarction (AAMI) by using pulsed wave Doppler tissue (PWDT) samplings of tricuspid annulus and RV free wall. Methods and results — The study group included 31 patients with AAMI and 20 age-matched controls. Conventional indexes of RV functions were the magnitude of tricuspid annular plane systolic excursion (TAPSE), and the transpulmonary and transtricuspid Doppler parameters. PWDT velocities were obtained by placing the sample volume at the lateral tricuspid annulus and the mid-segment of RV free wall; the peak systolic (S), early (E) and late (A) diastolic PWDT velocities and time intervals from ECG-Q wave to their peaks were analysed. Standard indexes were comparable except TAPSE that was significantly lower in AAMI-patients (p < 0.001). S velocities were similar; A of both regions (p = 0.018 and 0.012) and E of RV free wall (p = 0.011) were significantly increased in AAMI-group. Q-Sa intervals in both regions (p = 0.007 and 0.015) and Q-Ea of tricuspid annulus (p = 0.045) were significantly shorter in patients with AAMI.TAPSE and E of RV free wall had significant negative correlations with left ventricular systolic volume index and right atrial filling fraction (AFF), respectively (r = -0.46, p = 0.01 for both). A of tricuspid annulus had a positive correlation with left AFF (r = 0.42, p = 0.02). Conclusion — PWDT imaging of tricuspid annulus and RV free wall is capable to sensitively detect the adaptive mechanisms and unfavourable diastolic properties of RV dynamics in patients with AAMI.

Comparison of Coronary Flow Velocities Between Patients with Obstructive and Nonobstructive Type Hypertrophic Cardiomyopathy: Noninvasive Assessment by Transthoracic Doppler Echocardiography

Background: We aimed to compare coronary flow velocity (CFV) measurements of patients with nonobstructive (NHCM) and obstructive hypertrophic cardiomyopathy (HOCM) by using transthoracic Doppler echocardiography (TTDE). Methods and Results: In 11 patients with NHCM and 26 with HOCM, CFV in the distal left anterior descending (LAD) coronary was measured by TTDE (3.5 MHz) under the guidance of color Doppler flow mapping in addition to standard 2D and Doppler echocardiography. The results were compared with 24 normal participants who had no evidence of cardiac disease. Peak diastolic velocity of LAD was also higher in NHCM and HOCM than controls (52 ± 14 cm/sec and 54 ± 20 cm/sec vs 41 ± 11 cm/sec, respectively, P < 0.01). The analysis of systolic velocities revealed abnormal flow patterns in 16 (61%) patients with HOCM (12 systolic‐reversal flow and 4 no systolic flow) and 6 (54%) (5 reversal flow and 1 zero flow) patients with NHCM (−11 ± 30 cm/sec and −13 ± 38 cm/sec, vs 24 ± 9 cm/sec, respectively, P < 0.001). Linear regression analysis demonstrated no correlation between intraventricular pressure gradient and coronary flow velocities in HOCM patients. However, there were significant positive and negative correlations between septal thickness and diastolic and systolic velocities, respectively (r = 0.50, P < 0.002, and r =−0.43, P < 0.005). Conclusion: We conclude that the coronary flow velocity abnormalities are independent from the type of hypertrophic cardiomyopathy.

Prognostic implication of myocardial texture analysis in idiopathic dilated cardiomyopathy.

Abnormal myocardial acoustic properties have been reported in patients with idiopathic dilated cardiomyopathy (IDC). The aim of this study was to investigate the relationship between quantitative ultrasonic textural alterations of myocardium and clinical outcome in IDC.

Sympathetic overactivity in patients with left ventricular aneurysm in early period after anterior myocardial infarction : Does sympathetic activity predict aneurysm formation?

Left ventricular aneurysm (LVA) is an important complication of acute transmural myocardial infarction (MI) that bears great clinical significance because of high mortality. Heart rate variability (HRV) analysis is extensively used to evaluate autonomic modulation of sinus node and to identify patients at risk for an increased cardiac mortality. In this study, the authors evaluated HRV in patients with LVA in the early period after acute anterior wall MI. They compared 18 patients (7 men, 11 women, with an average age of 56.1 ±8.2 years) with LVA and 46 patients (34 men, 12 women, with an average age of 56.4 ±5.9 years) without LVA. Mean heart rate, low frequency (LF) and low-frequency/high-frequency (LF/HF) ratio were significantly higher and standard deviation of normal-to-normal RR intervals (SDNN), root mean square of successive differences (RMSSD), number of NN intervals that differed by more than 50 ms from adjacent interval divided by the total number of all NN intervals (PNN50), and HF were lower in the patients with LVA. A SDNN <78 ms separated the patients with aneurysm from those without aneurysm with a sensitivity of 78%, specificity of 83%, positive predictive accuracy of 79%; a LF/HF ratio >2.4 with a sensitivity of 92%, specificity of 88%, and positive predictive accuracy of 92%. Single-vessel disease increased the left ventricular aneurysm formation by 5.1 fold, total left anterior descending artery (LAD) occlusion by 3.1 fold, mean heart rate >75 beats/minute by 2.3 fold, SDNN <78 ms by 7.9 fold, and LF/HF ratio >2.4 by 12.9 fold, but well-developed collaterals decreased the aneurysm formation by 4.4 fold. As a result, HRV analysis supplies parameters with high predictive value for LVA formation in the early period after acute anterior MI. The higher sympathetic activity and reduced heart rate variability may be associated with a higher incidence of complications such as ventricular arrhythmias and increased mortality in patients with LVA.